In the last decade, several incidents of mentally ill citizens committing violent acts against other citizens have grabbed media attention and stoked the public’s fear that people diagnosed with a mental illness are violent predators. As a result, 44 states and the District of Columbia have passed Assisted Outpatient Treatment (AOT) statutes that allow civil courts to mandate mental health treatment for persons with a mental illness deemed to be potentially dangerous to themselves or others. There are also two bills under consideration in the U. S. Congress (S. 1945 and H.R. 2646) to reform mental health policy and expand the court-mandated treatment. This is the first time in 50 years that major bills in Congress have dealt with issues of mental health.

In AOT, courts can order people with psychiatric diagnoses such as schizophrenia, bipolar disorder and major depression into forced outpatient treatment, usually prescribed psychiatric medication. AOT, however, has not been proven to be an effective way to increase adherence to treatment, reduce hospital admission, reduce homelessness or limit criminal activity. More troubling, AOT laws, which are an attempted positive spin on coercive treatment, expand the policing powers of the government and deny the civil rights of an already marginalized and stigmatized segment of our population.

Instead of pursuing more policing power through AOT statutes, our government should be supporting the more effective solution of voluntary community treatment.

What You Need To Know

Only about 4% of violent incidents in the U.S. are committed by people who are mentally ill.

The expansion of AOT laws across the country has blurred what we consider to be “dangerousness” and places a segment of people with mental illness under community surveillance. The laws also serve as pre-emptive measures to force involuntary treatment on people who experience mental illness but who do not currently meet criteria for psychiatric hospitalization, haven’t had recent brushes with the criminal justice system, but are considered to be “deteriorating” and likely to meet the criteria for psychiatric hospitalization in the future.

To date, there have only been three studies conducted into the effectiveness of AOT programs and none have found support for a claim of effectiveness. In these studies, there were no differences in continued service use, reductions in hospital readmissions, length of hospital stays, rates of arrest, or rates of violent incidents or improvement in social functioning compared to patients on standard voluntary community treatment. The only positive outcome from these studies was patients were less likely to be victims of crimes.

Mental health providers do not like to work with involuntary patients.

Research shows mental health clinicians are traditionally poor at assessing and predicting a patient’s risk of “dangerousness.”

AOT laws can take away decision-making rights from patients who have not been legally classified as incompetent or dangerous.

AOT laws perpetuate the false belief that those with mental illness are dangerous and further stigmatizes already marginalized population.

Voluntary Treatment is a More Effective Option

When people feel that they have a choice in what services they receive, and they are involved in making treatment decisions, they are far more willing to seek treatment. Currently, there is an emphasis on patient-centered care in mental health, which is care that is respectful of and responsive to individual patient preferences, needs, and values.

There is no compelling reason to pass outpatient commitment laws that deny individuals with mental illness, who are neither determined to be incompetent nor dangerous, of their civil rights. AOT programs are not effective in achieving their intended goals. AOT is not a way to compensate for a low-quality community mental health system that is inadequately funded.

We need more recovery-oriented community mental health services. To deliver patient-centered care takes more time, effort, and skill on the part of practitioners. Consequently, more funds and more provider training are required. Voluntary mental health services are far more likely to pay off in the long term than ineffective short-term solutions like AOT.

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Jenelle

Beverly VanBuren

I am concerned that communities are grouping mentally ill citizens into high risk areas where they are more likely to be victims of crime because nobody takes them seriously when they call the police.

Val Marsh

Wonderful information. I'm grateful for Dr. Solomon's work. We need this kind of information to fight the wave of support for forced treatment in Congress. Makes me proud to be a social worker, to boot.

Jeffrey Draine

As usual Phyllis Solomon nails it right on the head! Rather than focus on a knee-jerk reaction to forced treatment--we could focus energy on all the myriad ways we could make mental health services more appealing, more obviously beneficial to a consumer--thus--more likely to draw people into care for the long haul.

A

Excellent article! Thank goodness this article shows up in a Google search for HR 2646.

About the author

Phyllis Solomon, PhD

Dr. Phyllis Solomon is internationally known for her research on clinical services and service system issues related to adults with severe mental illness and their families. Her research has specifically focused on family interventions, consumer provided services, and the intersection of criminal justice and mental health services. Her expertise is in mental health service delivery issues, psychiatric rehabilitation, and research methods. Her research has been recognized by such diverse organizations as American Association of Community Psychiatrists, US Psychiatric Rehabilitation Association, and Society for Social Work and Research.